Holston Medical Group

Practice Setting

Holston Medical Group (HMG) is a multispecialty, independent medical group located primarily across eastern Tennessee and southwest Virginia. Holston Medical Group has 60 locations in TN, VA, and NC with over 225 providers. HMG not only provides primary care services but additionally serves patients via specialties such as orthopedics, endocrinology, obstetrics and gynecology, gastroenterology and many more. HMG has outpatient diagnostic centers, outpatient surgery centers, and a dialysis clinic.

Currently two clinical pharmacists are deployed to different primary care clinics and one endocrinology clinic. The clinical pharmacists are primarily based out of the Kingsport, TN location which also serves as an education site for APPE students from ETSU Bill Gatton College of Pharmacy. Patients are managed with face-to-face encounters and more recently telehealth visits scheduled on individual pharmacists’ schedules. Clinical pharmacists at HMG manage patients based on a collaborative practice agreement and conduct patient visits for comprehensive medication managment. Most patients are referred to the clinical pharmacy department for management of diabetes, hyperlipidemia, hypertension, medication-assisted weight loss, anticoagulation, and for comprehensive medication reviews.

Clinical pharmacists are also highly involved with high-risk diabetes and hypertension programs with a large local employer. This initiative serves both to keep employees healthy and provides an incentive to members of this program for achieving their health goals. Currently pharmacy services are billed via evaluation and management codes at the provider level for two major commercial health plans. As more plans recognize pharmacists as providers both in TN and nationally we expect these contracts will expand.

Why was the pharmacy service developed? (Describe any compelling data collected prior to implementation)

Implemented in 1999, HMG partnered with the University of Tennessee College of Pharmacy to provide disease state management to patients and clinical training to residents in an innovative, multi-disciplinary setting. Clinical pharmacy services have since expanded to provide management to patients across several different clinic locations. Since that time, an additional 1 FTE clinical pharmacist practitioner position has been added as well as a full-time LPN to assist with clinical pharmacy patients.

What training, certification, credentialing, and practice agreement is utilized by the practice setting pharmacist(s)?

A standard collaborative practice agreement is utilized across all HMG clinics where pharmacists practice. Clinical pharmacists at HMG are expected to have completed a PGY1 residency and attain or have previously achieved board certification. Ongoing professional practice evaluations are completed quarterly and reviewed both by peers and the supervising physician.

What outcomes are being measured to evaluate the model's success? (Clinical metrics, revenue, cost-savings, patient satisfaction, etc.)

Outcomes measured include hemoglobin A1c, blood pressure, lipid panel, weight, and time in therapeutic range for anticoagulation. Provider satisfaction within the clinic has also been measured within the last year with positive results, showing the majority of providers say they have more time to work on other patient care activities and would recommend pharmacy services to other practices. More recently HMG is planning to evaluate clinical metrics and interventions pharmacists make daily via a web-based clinical measures dashboard.

How have you made this service sustainable? (Include billing, reimbursement, etc.) 

Clinical pharmacy services have been made sustainable by providing outcomes and project data to the board of directors on a regular basis. The board of directors at HMG understand and appreciate the value of having clinical pharmacists on staff and the services they provide to patients. We typically bill “incident-to” which limits our reimbursement on the majority of plans. Through our partnership with a large local employer we were able to achieve appropriate reimbursement for high risk diabetes and hypertension program participants.

Recently, one pharmacist was credentialed and contracted with Blue Cross Blue Shield of TN to bill at the provider level and a second pharmacist has a pending application. This is a huge opportunity for clinical pharmacy services at HMG since there are over 17,000 lives in BCBS TN plans. Certainly, as continued changes to provider status and expanded billing unfolds this will further provide sustainability for current clinical pharmacists and hopefully future positions.

How did you gain support of administrators, providers, and other key stakeholders to implement your practice model?

Support was gained through relationships with providers in the clinic who practice alongside clinical pharmacists daily. Having multiple pharmacy physician “champions" and a physician supervisor who is also a member of the board of directors has helped to further expand and improve HMG's practice model. The team meets quarterly with executive leadership to assure that goals remain aligned with the practice mission. Open communication and setting goals leads to a good working relationship.

One of the primary catalysts to get the process rolling was enacting state-level provider status for pharmacists through legislation championed by the Tennessee Pharmacists Association (TPA). Since the passage of this legislation, pharmacists have played an active role in supporting and directing the implementation of this law through TPA's ad hoc Ambulatory Care/Collaborative Practice Committee, including the development of tools, training, and resources focused on helping pharmacists with credentialing, contracting, and billing for pharmacists' services as medical providers.

What are some lessons learned while implementing your practice model that you would like to share

The most important first step is to listen. Listen to key stakeholders regarding a particular problem area or opportunity for improvement within the practice. Review and present data from the literature describing different ways that clinical pharmacists impact patient care. Based on practice needs, start small with one area of focus. Include providers in your work by sending them clinical notes and updates about his or her patients. Build relationships with patients through effective communication and shared decision making. Patients will tell others about the high level of care you provide and providers will want more patients seen by a clinical pharmacist.